Variable Direct Costs Research Articles

Assessing mortality outcomes of beta-lactam-allergic patients presenting with sepsis

ObjectiveTo determine the impact of reported beta-lactam allergies on in-hospital mortality and other clinical outcomes in patients who presented with severe sepsis or septic shock. MethodsThis single-center, retrospective cohort study was performed at a 35-bed emergency department in central Kentucky. Patients presenting with sepsis, aged 18years or older, were identified between October 2016 and June 2017. Results438 patients with severe sepsis and/or septic shock were identified. Rates of the combined endpoint of in-hospital mortality or transfer to hospice were similar in patients with a beta-lactam allergy (7.2%) versus those with no reported beta-lactam allergy (10.4%) (p=0.41). Time to initiation of antibiotic therapy was slightly longer in the beta-lactam allergic group (2.2h) versus those with no reported beta-lactam allergy (2.15h), but the difference was not statistically significant (p=0.993). Patients were 20.9% more likely to receive an appropriate empiric antibiotic, based off of retrospective culture review, if they did not report a beta-lactam allergy (p=0.009). This led to a delay in effective therapy of 1.59h in the reported beta-lactam allergy arm (p=0.037). ConclusionsAdequate documentation of beta-lactam allergies is vital to ensure timely and appropriate treatment in patients presenting with severe sepsis and septic shock. Choosing alternative treatment options results in increased time to effective antibiotics, reduced likelihood of covering cultures with first antibiotic, and increased total hospital and variable direct cost.

What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor?

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC. An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS). In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395-25,240). Median length of stay (LOS) was 8 (7-11.5) days and ICU stay was 1 (1-1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS. Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.

True Cost of Operating Room Time: Implications for an Orthopaedic Trauma Service

To derive an accurate estimate of the operating cost per minute for an orthopaedic trauma room. Retrospective economic analysis. Level II Trauma Center. Hospital cost-accounting system query. Direct fixed costs, direct variable costs, and hospital overhead. Operating room per minute costs include direct variable costs of $2.77, direct fixed costs of $2.47, and hospital overhead costs of $10.97. Total per minute costs amounted to $16.21. This does not include professional fees of anesthesiology or surgeons or the costs of soft goods or implants. This is the first published study to document the true per minute cost of an orthopaedic trauma operating room. Such information is valuable when defining the value of a dedicated operating room, negotiating employment contracts, defining call stipends, and brokering capital purchases for the orthopaedic trauma service. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Tibial Shaft and Plateau Fractures.

To determine whether a validated trauma triage tool can identify the middle-aged and geriatric trauma patients with tibial shaft and plateau fractures who are at the risk for costly admissions and poorer hospital quality measures. Prospective cohort study. Level-1 trauma center. Sixty-four patients older than 55 years hospitalized with isolated tibial shaft or plateau fractures. Patients with either isolated tibial plateau fractures or tibial shaft fractures over a 3-year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score. Length of stay, complications, discharge location, and direct variable costs. Sixty-four patients met inclusion criteria. Thirty-three patients (51.6%) presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (P < 0.001). Although 19 (90.5%) of the minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate- and high-risk patients were discharged home, respectively (P < 0.001). Higher-risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for intensive care unit-level care (P = 0.027 and P = 0.344, respectively). The total cost difference between the lowest- and highest-risk group was nearly 50% ($14,070 ± 8056 vs. $25,147 ± 14,471; mean difference, $11,077; P = 0.022). Application of the STTGMA triage tool allows for the prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Summary perioperative risk metrics within the electronic medical record predict patient-level cost variation in pancreaticoduodenectomy

BackgroundAutomated data extraction from the electronic medical record is fast, scalable, and inexpensive compared with manual abstraction. However, concerns regarding data quality and control for underlying patient variation when performing retrospective analyses exist. This study assesses the ability of summary electronic medical record metrics to control for patient-level variation in cost outcomes in pancreaticoduodenectomy. MethodsPatients that underwent pancreaticoduodenectomy from 2014 to 2018 at a single institution were identified within the electronic medical record and linked with the National Surgical Quality Improvement Program. Variables in both data sets were compared using interrater reliability. Logistic and linear regression modelling of complications and costs were performed using combinations of comorbidities/summary metrics. Models were compared using the adjusted R2 and Akaike information criterion. ResultsA total of 117 patients populated the final data set. A total of 31 (26.5%) patients experienced a complication identified by the National Surgical Quality Improvement Program. The median direct variable cost for the encounter was US$14,314. Agreement between variables present in the electronic medical record and the National Surgical Quality Improvement Program was excellent. Stepwise linear regression models of costs, using only electronic medical record–extractable variables, were non-inferior to those created with manually abstracted individual comorbidities (R2 = 0.67 vs 0.30, Akaike information criterion 2,095 vs 2,216). Model performance statistics were minimally impacted by the addition of comorbidities to models containing electronic medical record summary metrics (R2 = 0.67 vs 0.70, Akaike information criterion 2,095 vs 2,088). ConclusionSummary electronic medical record perioperative risk metrics predict patient-level cost variation as effectively as individual comorbidities in the pancreaticoduodenectomy population. Automated electronic medical record data extraction can expand the patient population available for retrospective analysis without the associated increase in human and fiscal resources that manual data abstraction requires.

Assessment of wastes recycling for deinking purposes in ozone assisted green process.

This study investigates techno-economic aspects of wastepaper recycling to optimize process efficiency and operating cost. The deinking was carried out using pulping followed by froth flotation. The development of a waste management process was achieved employing refinery wastewater to provide chemical reagents in pulping. Ozone was also used as a gas media in flotation to improve brightness and number of ink-spot and to reduce chemical oxygen demand (COD) simultaneously. An enhancement in the brightness was observed from 50.1 to 64.1% ISO that was superior to the brightness of virgin newspaper before printing (61.0% ISO). It was equivalent to a reduction of 55% (from > 100,000 to 45,058) in number of ink-spot. The quality of flotation effluent was assessed by measuring the COD and phthalocyanine concentration. The COD reduction of 67% (from 3250 to 1072mg/L) and phthalocyanine reduction of 85% (from 2 to 0.3mg/L) were achieved after 30min ozonation. According to the obtained results, approximately 67% of the direct (variable) cost reduced while the wastewater was used in pulping because of saving NaOH and water consumption. Associating the refinery and paper recycling wastewater treatment units, while taking into account the environmental and economic benefits of ozone, results in a quality paper and significantly preserves the environment.

Considering healthcare value and associated risk factors with postoperative urinary retention after elective laminectomy

BACKGROUNDMitigating common complications such as postoperative urinary retention (POUR) following elective spine surgery is prudent. Identifying patients at risk for POUR and recognizing associated factors, to avoid a more complicated postoperative episode should be a priority and easily achievable. Understanding the financial burden of complications, such as POUR, is also important for value-based healthcare, not only for providers, but for employers and payors as well. PURPOSEThe purpose of this study is to examine patient and surgical factors that may lead to increased risk for POUR and its associated cost following elective lumbar laminectomies. STUDY DESIGN/SETTINGThis is a retrospective study of the incidence of postoperative urinary retention after elective one- and two-level primary lumbar laminectomies. PATIENT SAMPLEWe followed patients undergoing one- and two-level primary elective lumbar laminectomies performed between April 2014 and December 2016. OUTCOME MEASURESPatient factors included age, gender, body-mass index, and comorbidities. Surgical factors included surgical time, intraoperative fluid volume requirements, anesthesia type, and surgical levels involved. Other outcome variables included length of stay, discharge disposition, 30-day all-cause readmissions and emergency department visits, 90-day complications, and variable direct costs. METHODSThe incidence of POUR was evaluated and compared with patient and surgical factors and cost-specific variables to identify correlations and potential risk for POUR after one- and two-level primary lumbar laminectomies. RESULTSAnalysis included 333 patients – 203 one-level laminectomies and 130 two-level laminectomies. The overall incidence of POUR was 17.4%. Age, male gender, and history of urinary retention were significantly associated with POUR. There was a significantly increased risk of POUR with increased surgical time, but not with anesthesia type. There were also no significant differences in body-mass index, other study comorbidities, intraoperative fluid requirements, readmission, emergency department visit, and complication rates between groups. On average, patients with POUR had a significantly longer length of stay than patients without POUR. In addition, more POUR patients were discharged to acute rehabilitation facilities and had higher average variable direct cost compared tonon-POUR patients. CONCLUSIONSPOUR is a significant risk after elective laminectomy. This study supports several widely accepted beliefs regarding POUR risk, while challenging others. It also highlights the burden of POUR development after surgery. At our institution, we developed a protocol supported by these findings.

Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System.

This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.

Cost-effectiveness of minimally invasive midline lumbar interbody fusion versus traditional open transforaminal lumbar interbody fusion.

The midline transforaminal lumbar interbody fusion (MIDLIF) using cortical screw fixation is a novel, minimally invasive procedure that may offer enhanced recovery over traditional open transforaminal lumbar interbody fusion (TLIF). Little information is available regarding the comparative cost-effectiveness of the MIDLIF over conventional TLIF. The purpose of this study was to compare cost-effectiveness of minimally invasive MIDLIF with open TLIF. From a prospective, multisurgeon, surgical database, a consecutive series of patients undergoing 1- or 2-level MIDLIF for degenerative lumbar conditions was identified and propensity matched to patients undergoing TLIF based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists Physical Status Classification System (ASA) class, and levels fused. Direct costs at 1 year were collected, including costs associated with the index surgical visit as well as costs associated with readmission. Improvement in health-related quality of life was measured using EQ-5D and SF-6D. Of 214 and 181 patients undergoing MIDLIF and TLIF, respectively, 33 cases in each cohort were successfully propensity matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA class, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. Variable direct costs at 1 year were $2493 lower in the MIDLIF group than in the open TLIF group (mean $15,867 vs $17,612, p = 0.073). There was no difference in implant (p = 0.193) or biologics (p = 0.145) cost, but blood utilization (p = 0.015), operating room supplies (p < 0.001), hospital room and board (p < 0.001), pharmacy (p = 0.010), laboratory (p = 0.004), and physical therapy (p = 0.009) costs were all significantly lower in the MIDLIF group. Additionally, the mean length of stay was decreased for MIDLIF as well (3.21 vs 4.02 days, p = 0.05). The EQ-5D gain at 1 year was 0.156 for MIDLIF and 0.141 for open TLIF (p = 0.821). The SF-6D gain at 1 year was 0.071 for MIDLIF and 0.057 for open TLIF (p = 0.551). Compared with patients undergoing traditional open TLIF, those undergoing MIDLIF have similar 1-year gains in health-related quality of life, with total direct costs that are $2493 lower. Although the findings were not statistically significant, minimally invasive MIDLIF showed improved cost-effectiveness at 1 year compared with open TLIF.

Implementing Pediatric Fluoride Varnish Application in a Rural Primary Care Medical Office: A Feasibility Study.

The objective of this study was to determine if the application of fluoride varnish (FV) to children 5 years and under was acceptable and practical for health care providers in a rural primary care office. We employed a quasi-experimental study design comprised of providers who received education and training in FV application. Pre- and post-study surveys regarding barriers and facilitators were administered. Data was collected on the number of FV applications, time spent on procedure, perceived barriers, and overall cost. The total direct variable cost of providing FV was $4.35 per procedure, resulting in an $11.85 profit. FV application increased 9.57%. Potential barriers were lack of proper supplies, lack of adequate support staff, and lack of additional financial compensation for providers. FV application is a service that can be delivered in a rural practice with existing resources, but the initiative needs support from practice management.

A tiered approach to optimize pediatric laparoscopic appendectomy outcomes

Background/PurposeSurgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost. MethodsAppendectomies performed at a large-volume tertiary care children's hospital from 1/2015–12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes. ResultsA total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes. ConclusionsSILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year. Type of StudyTreatment Study. Level of EvidenceLevel III.

Patterns of Health Care Costs Due to External Ventricular Drain Infections

External ventricular drain (EVD) infections are a significant cause of morbidity among neurosurgical patients and have been correlated with increased length of hospital stay and longer requirements for intensive care. To date, no studies have examined the financial impact of EVD infections. Patients who underwent EVD placement between December 2010 and January 2016 were included in the study. Clinical records were retrospectively reviewed and health care cost data were obtained from the hospital's finance department. Clinical information included patient demographics, details from the hospital course, and outcomes. Total costs, direct/indirect, and fixed/variable costs were analyzed for every patient. Over the 5-year study period, 246 EVDs were placed in 243 patients with an overall infection rate of 9.9% (N= 24). The median EVD duration for infected versus noninfected patients was 19 and 9 days, respectively (P<0.0001). Median length of intensive care unit stay also was increased for patients with EVD infection (30 days vs. 13 days, P < 0.0001). Total health care costs were significantly greater for infected patients (US$ 168,692 vs. US$ 83,919, P < 0.0001). This trend was comparable for all other cost subtypes, including fixed-direct costs, fixed-indirect costs, variable direct costs, and variable-indirect costs. EVD infection has a substantial effect on clinical morbidity and healthcare costs. These results demonstrate the imperative need to improve EVD infection prevention, particularly in the setting of a value-based health care system.

Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre

BackgroundReducing costs while increasing or maintaining quality is crucial to delivering high value care.ObjectiveTo assess the impact of a hospital value-based management programme on cost and quality.DesignTime series analysis of...

A Surgeon Scorecard Is Associated with Improved Value in Elective Primary Hip and Knee Arthroplasty.

Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs. We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05. After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05). The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes. Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery.

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study

BackgroundArmenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.MethodsThis was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.ResultsThe mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government’s reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers’ concern.ConclusionThe study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

2183. Financial Cost, Length of Stay, and Patient Experience Associated with Healthcare-Associated Infections Across a 43 Hospital Network

BackgroundReduction of healthcare-associated infections (HAIs) is critical to improve patient safety and hospital quality. However, not all HAI-associated outcomes are well studied. We examined several of these—the financial and length of stay (LOS) burden of HAIs and patient experience of care.MethodsNational Healthcare Safety Network-reported catheter-associated urinary tract infections (CAUTI), C. difficile infections (CDI), central line-associated bloodstream infections (CLABSI), MRSA bacteremia, and colon surgery surgical site infections (SSI-COLO) were queried for the first 9 months of 2016 from 43 hospitals. Patients with an HAI were matched to controls on hospital and primary diagnosis to create a retrospective case–control study. CAUTI and CLABSI patients were matched to controls with associated device codes. LOS and total direct variable cost (TDVC) were collected for all HAI and control patients. If patients returned a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, their likelihood to recommend (LTR) response was additionally analyzed.ResultsData were analyzed for 123 CAUTI, 1,116 CDI, 166 CLABSI, 58 MRSA, and 127 SSI-COLO case–control pairs across 43 hospitals. TDVC per case was significantly higher among HAI cases than controls for CDI ($6,484), CLABSI ($14,646), and SSI-COLO ($9,770; figure 1). LOS was significantly higher for cases across all HAI groups, with attributable differences of 7.6 days for CAUTI, 6.4 for CDI, 9.7 for CLABSI, 7.4 for MRSA, and 4.5 for SSI-COLO (Figure 2). Of 3,180 subjects, 198 returned HCAHPS surveys. Response rate of “Yes, definitely” to LTR for 85 HAI patients was 63.5% compared with 72.6% for 113 control patients (Figure 3). ConclusionThis is the first investigation to our knowledge pairing patient experience of care data with TDVC and LOS for HAI patients. HAIs have a significant impact on patient experience, cost, and length of stay―further supporting the importance of preventing HAIs.Disclosures R. Olmsted, Ethicon, Inc.: Speaker’s Bureau, Speaker honorarium; APIC: External faculty HRET/CDC STRIVE project, Speaker honorarium.

Identify and monitor clinical variation using machine intelligence: a pilot in colorectal surgery.

Standardized clinical pathways are useful tool to reduce variation in clinical management and may improve quality of care. However the evidence supporting a specific clinical pathway for a patient or patient population is often imperfect limiting adoption and efficacy of clinical pathway. Machine intelligence can potentially identify clinical variation and may provide useful insights to create and optimize clinical pathways. In this quality improvement project we analyzed the inpatient care of 1786 patients undergoing colorectal surgery from 2015 to 2016 across multiple Ohio hospitals in the Cleveland Clinic System. Data from four information subsystems was loaded in the Clinical Variation Management (CVM) application (Ayasdi, Inc., Menlo Park, CA). The CVM application uses machine intelligence and topological data analysis methods to identify groups of similar patients based on the treatment received. We defined "favorable performance" as groups with lower direct variable cost, lower length of stay, and lower 30-day readmissions. The software auto-generated 9 distinct groups of patients based on similarity analysis. Overall, favorable performance was seen with ketorolac use, lower intra-operative fluid use (< 2000cc) and surgery for cancer. Multiple sub-groups were easily created and analyzed. Adherence reporting tools were easy to use enabling almost real time monitoring. Machine intelligence provided useful insights to create and monitor care pathways with several advantages over traditional analytic approaches including: (1) analysis across disparate data sets, (2) unsupervised discovery, (3) speed and auto-generation of clinical pathways, (4) ease of use by team members, and (5) adherence reporting.

Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients

BackgroundPreoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs. MethodsThis retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015). ResultsThe 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P < .001). Of the 98% of post-implementation patients screened, 74% had at least 1 risk factor identified. Obstructive sleep apnea was the most common risk factor (52%), followed by depression (22%) and obesity (body mass index > 40 kg/m2 or 35-40 kg/m2 with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P < .001) and lower average total direct variable costs excluding implants ($5409 vs $5852, P < .001). There was no difference in patients discharged home (90% vs 89%, P = .53) or 90-day readmissions (4.1% vs 4.3%, P = .93). ConclusionIn our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization.

An Analysis of the Cost-Effectiveness of Spinal Versus General Anesthesia for Lumbar Spine Surgery in Various Hospital Settings.

Study Design:Retrospective chart review.Objective:To determine the relative cost-effectiveness of spinal anesthesia and general anesthesia for lumbar laminectomy and microdiscectomy surgery performed in an academic versus private practice hospital setting.Methods:The authors retrospectively reviewed charts of 188 consecutive patients who underwent lumbar laminectomy or microdiscectomy by a single surgeon from 2012 to 2016 at either an academic or a private practice hospital setting. Intraoperative and postoperative outcomes were recorded and direct variable costs were calculated.Results:At the academic institution, the direct cost of a lumbar laminectomy or microdiscectomy surgery under general anesthesia was determined to be 9.93% greater than with spinal anesthesia (P = .040). The greatest difference was seen with operating room costs, in which general anesthesia was associated with 18.74% greater costs than spinal anesthesia (P = .016). There was no significant difference in cost at the private practice hospital setting.Conclusions:We conclude that use of spinal anesthesia for lumbar laminectomy leads to less operating room, postanesthesia care unit, and anesthesia times, lower levels of postoperative pain, and no increased rate of other complications compared with general anesthesia at an academic institution as compared to a private practice setting. Spinal anesthesia is 9.93% less expensive than general anesthesia, indicating substantial cost-saving potential. With no sacrifice of patient outcomes and the added benefit of less pain and recovery time, Spinal anesthesia represents a more cost-effective alternative to general anesthesia in lumbar spine surgery in the academic hospital setting.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Increasing Value: Lumbar Spine Surgery: 66. Cost-benefit analysis of intraoperative EMG for pedicle screw placement in routine lumbar fusions

BACKGROUND CONTEXT Advances in intraoperative neuromonitoring have increased the safety and shown clear benefit for complex spine cases. However, controversy exists regarding the utility of intraoperative EMG for identification of pedicle wall breaches for uncomplicated posterolateral lumbar fusions. PURPOSE To perform a cost-benefit analysis of pedicle screw stimulation via triggered EMG in routine lumbar pedicle screw cases. STUDY DESIGN/SETTING Prospective case series. PATIENT SAMPLE Patients undergoing primary instrumented posterior lumbar fusion with pedicle screws from L1 to S1. OUTCOME MEASURES EMG screw stimulation, need for screw repositioning, variable direct cost. METHODS A prospective study was conducted at single institution. Patients undergoing instrumented posterolateral lumbar fusion were monitored with intraoperative triggered EMGs. Pedicle screws were placed freehand from L1 to S1 by attending physicians and spine fellows. Concern for pedicle breach was identified with a screw stimulation value less than 10 mA. RESULTS There were 145 cases with a total of 725 pedicle screws placed. Mean age was 57.8±14.2 years, OR time was 238±95 minutes, EBL was 426.8±354.3cc. Mean number of surgical levels fused was 2.7±1.1. 686 (95%) screws stimulated at >10 mA and 39 (5%) screws stimulated at CONCLUSIONS Only 1% of the 725 lumbar pedicle screws placed in 8 of 145 cases required repositioning. Due to the infrequency of pedicle wall breaches and the cost of ION, the utility of this modality in straightforward lumbar fusions should be critically evaluated. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.